Understanding eating and drinking behaviours in Pakistani university students: A conceptual model through qualitative enquiry.

Excess weight in Pakistan's university students is on the rise and is driven by their maladaptive eating behaviours. Practitioners in Pakistan have adopted Western conceptual models to understand obesogenic eating behaviours. However, these models provide incomplete explanations as they miss important culturally specific determinants for such eating behaviours. The goals of this study were two-fold: first, to explore Pakistani university students' perception of their obesity-related eating behaviours and attitudes; second, to develop a culturally sensitive model of obesogenic eating behaviours in university students from Pakistan. Semi-structured interviews were used with twenty-four Pakistani university students who were categorised as obese using the Body Mass Index according to Asia-Specific cut-offs. Interviews were transcribed, translated, and then analysed through a Grounded Theory methodology. Six major categories emerged from interviews: (1) Obesogenic Eating Habits (Social Eating, Emotional Eating, and Eating Whatever and Whenever You Want); (2) Beliefs about Food in the Culture; (3) Neither Too Fat nor Too Thin body belief (4) Student Life Attitudes; (5) Student Stressors; (6) Inconsistent Weight-Control Strategies. A model was developed with cultural beliefs about food, attitudes towards student-life, and stressors as important determinants of students' obesogenic eating habits, while inconsistent weight-control strategies contributed to further weight gain. The findings highlight the importance of identifying culturally specific determinants of eating behaviours among university students in Pakistan. This emerging model can be used to guide the development of future quantitative and also longitudinal studies aimed at identifying targets for therapeutic interventions to manage obesogenic eating behaviours in Pakistani university students.

Parental Bonding and Body Mass Index in a Female Community Sample: The Mediating Role of Eating Disorder Thoughts and Core Beliefs.

BACKGROUND: It is likely that disrupted early parent-child relationships, eating disorder related cognitions and negative self-beliefs are relevant to some women who are overweight/obese. AIMS: This study tested the hypotheses that disrupted parent-child relationships would be linked to higher body mass index (BMI) and that this relationship would then be mediated by cognition. METHOD: A group of women were recruited from the community and completed measures of eating disorder (ED) thoughts, negative self-beliefs, and parental bonding. Individual body mass indices (BMIs) were calculated. RESULTS: One hundred and eighteen women completed the study. There was a relationship between parental bonding and higher BMI. As hypothesized, the relationship between parental bonding (as measured by maternal care, and paternal overprotection) and BMI appeared to be mediated by a range of ED thoughts, and some negative self-beliefs. CONCLUSION: The cognitions measured here, both ED related cognitions and negative self-beliefs, may be a useful target when considering psychological treatment for women who are overweight or obese.

Psychological therapy for anxiety in bipolar spectrum disorders: a systematic review.

Comorbid anxiety is common in bipolar spectrum disorders [BPSD], and is associated with poor outcomes. Its clinical relevance is highlighted by the "anxious distress specifier" in the revised criteria for Bipolar Disorders in the Diagnostic and Statistical Manual 5th Edition [DSM-5]. This article reviews evidence for the effectiveness of psychological therapy for anxiety in adults with BPSD (bipolar I, II, not otherwise specified, cyclothymia, and rapid cycling disorders). A systematic search yielded 22 treatment studies that included an anxiety-related outcome measure. Cognitive behavioural therapy [CBT] for BPSD incorporating an anxiety component reduces anxiety symptoms in cyclothymia, "refractory" and rapid cycling BPSD, whereas standard bipolar treatments have only a modest effect on anxiety. Preliminary evidence is promising for CBT for post-traumatic stress disorder and generalised anxiety disorder in BPSD. Psychoeducation alone does not appear to reduce anxiety, and data for mindfulness-based cognitive therapy [MBCT] appear equivocal. CBT during euthymic phases has the greatest weight of evidence. Where reported, psychological therapy appears acceptable and safe, but more systematic collection and reporting of safety and acceptability information is needed. Development of psychological models and treatment protocols for anxiety in BPSD may help improve outcomes.

Cognitive reappraisal of peer rejection in depressed versus non-depressed adolescents: functional connectivity differences.

BACKGROUND: Depression is the most common psychiatric disorder in adolescence, and is characterised by an inability to down-regulate negative emotional responses to stress. Adult studies suggest this may be associated with reduced functional connectivity between prefrontal and subcortical regions, yet the neurological mechanisms in adolescence remain unclear. METHODS: We developed a novel, age-appropriate, reappraisal paradigm to investigate functional connectivity during reappraisal of a real-life source of stress in 15 depressed and 15 non-depressed adolescents. During fMRI, participants i) attended to, and ii) implemented reappraisal techniques (learnt prior to fMRI) in response to, rejection. RESULTS: Reappraisal reduced negative mood and belief in negative thoughts in both groups alike, however during reappraisal (versus attend) trials, depressed adolescents showed greater connectivity between the right frontal pole and numerous subcortical and cortical regions than non-depressed adolescents. CONCLUSIONS: These findings tentatively suggest that, when instructed, depressed adolescents do have the ability to engage neural networks involved in emotion regulation, possibly because adolescence reflects a period of heightened plasticity. These data support the value of cognitive reappraisal as a treatment tool, identify neural markers that could be used to optimise current therapies, and lay the foundations for developing novel neuroscientific techniques for the treatment of adolescent depression.

Changes in automatic threat processing precede and predict clinical changes with exposure-based cognitive-behavior therapy for panic disorder.

BACKGROUND: Cognitive behavioral therapy (CBT) is an effective treatment for emotional disorders such as anxiety or depression, but the mechanisms underlying successful intervention are far from understood. Although it has been a long-held view that psychopharmacological approaches work by directly targeting automatic emotional information processing in the brain, it is usually postulated that psychological treatments affect these processes only over time, through changes in more conscious thought cycles. This study explored the role of early changes in emotional information processing in CBT action. METHODS: Twenty-eight untreated patients with panic disorder were randomized to a single session of exposure-based CBT or waiting group. Emotional information processing was measured on the day after intervention with an attentional visual probe task, and clinical symptoms were assessed on the day after intervention and at 4-week follow-up. RESULTS: Vigilance for threat information was decreased in the treated group, compared with the waiting group, the day after intervention, before reductions in clinical symptoms. The magnitude of this early effect on threat vigilance predicted therapeutic response after 4 weeks. CONCLUSIONS: Cognitive behavioral therapy rapidly affects automatic processing, and these early effects are predictive of later therapeutic change. Such results suggest very fast action on automatic processes mediating threat sensitivity, and they provide an early marker of treatment response. Furthermore, these findings challenge the notion that psychological treatments work directly on conscious thought processes before automatic information processing and imply a greater similarity between early effects of pharmacological and psychological treatments for anxiety than previously thought.

Positive core beliefs and their relationship to eating disorder symptoms in women.

Positive core beliefs, compared with negative self or negative core beliefs, are relatively neglected in the eating disorder (ED) research literature, despite their significance in treatment. Using a sample of younger women and relevant to those who typically experience EDs, this study outlines a new measure of positive core beliefs and examines its psychometric properties. On the basis of factor analysis, two subscales were developed: positive social self beliefs and positive individual self beliefs. The measure had good internal consistency and good construct validity. Positive individual self beliefs predicted low levels of ED symptoms when confounds were controlled. Positive social self beliefs predicted low levels of depressive symptoms, when confounds were controlled. Positive core beliefs would benefit from further study in subclinical and clinical ED groups of younger women.

Understanding your own and other's minds: the relationship to eating disorder related symptoms.

A study using a cross-sectional survey design examined whether eating disorder (ED) related symptoms are associated with understanding one's own and others' minds. A non-clinical sample of 145 women completed self-report questionnaires and recorded their emotional, cognitive and behavioural responses to descriptions of scenarios (vignettes). Responses to scenarios were made from the perspective of self, an attachment figure and a same sex acquaintance. Data were analysed using multiple regression statistics with ED related symptoms as the dependent variable. High levels of ED related symptoms were associated with 'concretised' understanding of own emotions (i.e. a greater number of food related responses), but sophisticated understanding of same sex acquaintance's emotions. They were associated with fewer positive thoughts for self, fewer negative emotions about their own behaviour, and more food responses for same sex acquaintance's behaviour. Similarities and differences were observed in the different perspectives. Limitations are discussed. Implications for further research related to this topic and relevant to EDs are briefly summarised.

The relationship between body weight (body mass index) and attachment history in young women.

OBJECTIVE: This study investigated whether attachment history predicts unique variance in body mass index in young women. METHOD: A cross-sectional design was employed. One hundred and forty five women completed self report measures of attachment history and psychological symptoms. RESULTS: The findings indicated that negative parental discipline predicted significant variance in body mass index when common variance associated with demographic and psychological symptom measures was taken into account. CONCLUSIONS: It is concluded that attachment history may contribute to overweight and obesity and may be an important factor to consider in the prevention and treatment of overweight in women.

Development and validation of the Supervisory Relationship Questionnaire (SRQ) in UK trainee clinical psychologists.

OBJECTIVE: To develop a valid and reliable measure of the supervisory relationship (SR) from the supervisee perspective. DESIGN: A cross-sectional questionnaire design was used with a repeated measures component for a sub-sample. METHOD: Qualitative data obtained from a previous study and from review of the literature were used to construct a 111 item self-report questionnaire measure [Supervisory Relationship Questionnaire (SRQ)]. This was administered to 284 British trainee clinical psychologists. Eighty-five participants completed the SRQ a second time to establish its test-retest reliability. RESULTS: Principal components analysis (PCA) identified six components of the SRQ. Three of these reflected the 'facilitative' relationship characteristics of the SR and were labelled 'safe base', 'commitment' and 'structure'. The second set of components reflected the educative and evaluative functions of supervision. These were labelled 'reflective education', 'role model' and 'formative feedback'. Safe base accounted for the greatest proportion of variance in SRQ scores (52 per cent). Analyses using the six subscales subsequently derived from the PCA, revealed the SRQ to have high internal reliability, good test-retest reliability and good construct (convergent and divergent) validity. A preliminary test of predictive validity was conducted. CONCLUSIONS: The SRQ (six subscales, total of 67 items) is a valid and reliable measure of the SR from the supervisee perspective. The present findings support existing models of the SR, and its distinct nature during training as an educative and evaluative process. The SRQ is a promising tool for further research, and is likely to be useful in supervisor training and clinical settings.

Emotional processing in women with anorexia nervosa and in healthy volunteers.

Emotional processing was investigated in patients with anorexia nervosa (AN) and in healthy volunteers (HVs) using self report questionnaires and information processing tasks. Compared to the HVs, patients with AN had lower levels of self reported emotional awareness and expression. They also responded more slowly to, correctly identified fewer emotions and misclassified more emotions in a facial recognition task, and responded more slowly to, and recalled fewer, self-referent emotion words. There were no key differences between the two groups on non-emotional control tasks, suggesting that their deficits are specific to emotional information and not a general feature of the illness. Analysis indicated that some, but not all, of the differences found remained when depressive symptoms were taken into account. Exploratory analysis of sub-groups (medicated vs. unmedicated patients) indicated that those who were on medication may perform very differently from those who were not on medication, including when level of depression is controlled, although it is important to emphasise that these findings are preliminary. The implications of a deficit in emotional processing in those with AN, including discussion of the specific differences found between medicated and unmedicated, are discussed in relation to previous findings in the area. A number of implications for future research, theory and therapy with those with AN are discussed.

Metacognition in patients with anorexia nervosa, dieting and non-dieting women: a preliminary study.

OBJECTIVE: To explore metacognition in women with anorexia nervosa (AN), dieting and non-dieting women. METHOD: A cross-sectional study between groups design compared women with AN (n = 15), normal dieters (n = 17) and non-dieters (n = 18). A semi-structured interview was used to explore presence and content of explicit metacognitions and use of metacognitive control strategies. RESULTS: Explicit metacognitions and metacognitive control strategies were present in all three groups of women. There were group differences in amount and function of metacognitive activity and trends in the qualitative data suggested participants with AN believed that their thoughts were abnormal and uncontrollable. They used six metacognitive strategies more than control groups and were less successful at using thought re-appraisal and attending to body and others. Half of participants with AN reported using these strategies to deliberately make themselves feel worse. DISCUSSION: It is suggested that metacognitive activity may play a role in the maintenance of AN, particularly in reinforcing negative self-evaluations.

The experience of 'feeling fat' in women with anorexia nervosa, dieting and non-dieting women: an exploratory study.

OBJECTIVE: To provide a preliminary, systematic exploration of some features associated with the experience of 'feeling fat'. METHOD: Women with anorexia nervosa (N = 16), women who were dieting (N = 15) and non-dieting women (N = 17) took part in a semi-structured interview. RESULTS: Feeling fat was common in all three groups of women. It was associated with distress, negative emotions, internal and external body sensations, images in a range of modalities, negative self beliefs and a first memory of feeling fat. Differences specifically characteristic of those with anorexia nervosa were identified, including feeling fatter, greater associated distress, more negative emotions, greater 'emotional' belief in cognitions, a richer experience, an earlier first memory, greater strength of negative self beliefs and a link to restricting behaviour. Some qualitative data are reported. CONCLUSIONS: The experience of feeling fat can be 'unpacked' in a way that may be useful in cognitive therapy for those with anorexia nervosa.

Metacognition in anorexia nervosa, dieting and non-dieting controls: a preliminary investigation.

OBJECTIVE: The aim of the current study was to provide a preliminary investigation of the presence of metacognition in anorexia nervosa (AN). METHOD: Female participants with a history of AN (N=16), dieters (N=15) and non-dieting controls (N=17) completed self-report questionnaires, including one assessing five dimensions of metacognition. RESULTS: Those with a history of AN, compared to both control groups, had higher scores on metacognition; indicating higher levels of uncontrollability and danger; cognitive confidence; need for control; and cognitive self-consciousness, but not higher levels of positive beliefs. CONCLUSION: Metacognition is worthy of further study in those with a history of AN.

The eating disorder belief questionnaire: psychometric properties in an adolescent sample.

The current study aimed to investigate the psychometric properties of the Eating Disorder Belief Questionnaire in older adolescent females. Three hundred and sixty-seven girls aged 17 or 18 who were in secondary school education completed the Eating Disorder Belief Questionnaire, the Beck Depression Inventory and the Eating Attitudes Test. They also provided information on height and weight. The Eating Disorder Belief Questionnaire had an almost identical factor structure to that previously found in adult women, although the factors were not quite as discrete as those in the original validation study. Internal consistency for each factor was high and construct validity (including convergent and criterion related validity) was very good. The almost identical factor structure, and other good psychometric properties, found for the Eating Disorder Belief Questionnaire in the current study suggests that it is an appropriate measure for use in clinical settings and in research studies involving 17-18 year old girls. This includes older adolescents with eating disorders. The possibility that adolescents show a developmental tendency for less separation between the constructs assessed, when compared with adults, is of particular interest, and requires further exploration.

Beliefs and their relationship to eating attitudes and depressive symptoms in men.

OBJECTIVE: The applicability of the cognitive model of eating disorders, particularly the role of deeper level beliefs, has not yet been investigated in men. The current study investigated the relationship between negative self-beliefs, underlying assumptions about weight, shape and eating, eating attitudes and depressive symptoms in a student sample of young men. METHOD: Fifty-six young male students completed self-report questionnaires, including measures of deeper level beliefs previously found to be typical of women with eating disorders and women with disturbed eating attitudes. RESULTS: Eating attitudes in the student sample of young men were best predicted by one underlying assumption, i.e. control over eating. Depressive symptoms were best predicted by negative self-beliefs. CONCLUSION: Negative self-beliefs and underlying assumptions about weight, shape and eating relate to eating attitudes and depressive symptoms in a student sample of young men as would be predicted by cognitive theory. Cognitive models of eating disorders, particularly those incorporating deeper level beliefs may, therefore, be applicable to young men.

The specific content of core beliefs and schema in adolescent girls high and low in eating disorder symptoms.

The specific content of core beliefs and schema in adolescent girls high and low in eating disorder symptoms was investigated using the Eating Disorder Belief Questionnaire (EDBQ)-negative self-beliefs sub-scale and Young Schema Questionnaire (YSQ). Girls with high Eating Attitude Test (EAT) scores had higher scores on both measures (using total and sub-scale scores) than girls with low EAT scores. However, all scores were related to eating disorder as well as depressive symptoms. Analysis of individual items on the EDBQ and YSQ found that scores on all EDBQ, but not all YSQ items, differed between the two groups, with higher scores in the high EAT group. However, a number of individual items (on both measures) in the high EAT group, as well as in the low EAT group, were related specifically to eating disorder symptoms and not also to depressive symptoms.

Core beliefs and the presence or absence of eating disorder symptoms and depressive symptoms in adolescent girls.

OBJECTIVE: Core beliefs specific to eating disorder and depressive symptoms were investigated in four groups of adolescent girls well matched on these symptoms. METHOD: A total of 272 girls were included and two measures of core beliefs were compared. The measures were the Young Schema Questionnaire (YSQ) and the Negative Self-Beliefs subscale of the Eating Disorder Belief Questionnaire (EDBQ). RESULTS: One-way analyses of variance found that both measures distinguished a "healthy" group and a group high on depressed symptoms, but not one high on eating disorder symptoms. Both measures also distinguished the unhealthy group from a high eating disorder symptom group, but only the EDBQ subscale distinguished this group from the group high on depressive symptoms. Discriminant function analysis indicated that both measures identified beliefs specific to depression but only the EDBQ subscale was able to identify beliefs specific to eating disorder symptoms. These beliefs were I'm stupid and I'm ugly. DISCUSSION: In an analogue population at least, the EDBQ negative self-beliefs subscale may be a more sensitive measure of eating disorder related core beliefs than the YSQ. The practical difficulties of replicating the current study in a clinical population are discussed, and a next step is proposed for future research on this topic.

Cognitive theory in anorexia nervosa and bulimia nervosa: progress, development and future directions.

Important developments have taken place in cognitive theory of eating disorders (EDs) (and also in other disorders) since the review paper published by M.J. Cooper in 1997. The relevant empirical database has also expanded. Nevertheless, cognitive therapy for anorexia nervosa and bulimia nervosa, although helpful to many patients, leaves much to be desired. The current paper reviews the relevant empirical evidence collected, and the theoretical revisions that have been made to cognitive models of eating disorders, since 1997. The status and limitations of these developments are considered, including whether or not they meet the criteria for "good" theory. New theoretical developments relevant to cognitive explanations of eating disorders (second generation theories) are then presented, and the preliminary evidence that supports these is briefly reviewed. The lack of integration between cognitive theories of EDs and risk (vulnerability) factor research is noted, and a potential model that unites the two is noted. The implications of the review for future research and the development of cognitive theory in eating disorders are then discussed. These include the need for study of cognitive constructs not yet fully integrated (or indeed not yet applied clinically) into current theories and the need for cognitive theories of eating disorders to continue to evolve (as they have indeed done since 1997) in order to fully integrate such constructs. Treatment studies incorporating these new developments also urgently need to be undertaken.

Parental bonding and eating disorder symptoms in adolescents: the meditating role of core beliefs.

This study aimed to investigate the mediating role of early maladaptive schemas in the relationship between parental bonding and eating disorder symptoms in a group of female adolescents. Three hundred and sixty-seven female adolescents completed the Parental Bonding instrument [PBI; Brit. J. Med. Psychol. 52 (1979) 1-10], the Young Schema Questionnaire short version [YSQ; Young, J. E. (1998). The Young Schema Questionnaire: Short form. Available at ], and the Eating Attitudes Test [EAT; Psychol. Med. 9 (1979) 273-279]. Two underlying schemas, defectiveness/shame and dependence/incompetence, were perfect mediators in the relationship between parental bonding and eating disorder symptoms. Schemas relating to both shame and dependency may be important in determining the effect that parental bonding has on eating disorder symptoms in a sample of female adolescent schoolgirls.

A cognitive model of bulimia nervosa.

This paper describes a new cognitive model of bulimia nervosa. It provides a detailed account of the development of the disorder and explains, in detail and encompassing cognition, behaviour, emotion, and physiology, how binge eating is maintained. Relevant maintaining factors include positive beliefs about eating, negative beliefs about weight and shape, permissive thoughts, and thoughts of no control. Relevant developmental factors include negative early experiences, negative self-beliefs, schema compensation processes, and different types of underlying assumption. Recent empirical findings on which the new model is based, and which support the model, are described. Existing observations and findings are also presented, and their consistency with the new model is confirmed. Novel features of the model are highlighted, and phenomena unexplained by existing cognitive models of bulimia nervosa, including treatment failure and relatively poor outcome following treatment with cognitive therapy, are assessed in the light of the new model. The relationship to recent findings on the role of dieting in bulimia nervosa and to developments in the understanding or normal eating is considered. Implications for basic and treatment-related research are then discussed. Finally, the clinical implications of the new model, including the use of schema-focused techniques, are briefly discussed.